Mental Health

Time for better handovers in healthcare… still. What does the evidence say?

This blog piece will be padded out more in due course but am uploading now at the request of a dear social media friend (who I encourage you to follow) – @m4delen …

This came about following her tweet on patient involvement during handovers within inpatient care. See here. I was asked to put up one of my university papers which was submitted during my evidence based practice module in mental health nursing. I think I got a mark of 89%. My highest one! Here it is cut and pasted:

A report into best practice within a nursing handover on psychiatric wards


This report considers evidence based practice within a nursing handover on psychiatric wards.  Handover is defined as ‘the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis.’ (Bywaters et al. 2004).  However, what constitutes a good handover has been difficult to elicit on placement, with no formal training, and my confusion compounded by witnessing a variety of handover styles.  I am; therefore, keen to explore this area to enable me to provide the best possible care for my patients.

There is an increased drive to improve handovers due to factors such as the increase of shift pattern working and more individuals caring for patients (Bywaters et al. 2004).  This results in more handovers and a safety risk at each interval (WHO, 2007).  Handover communication between units and amongst care teams might not include all essential information, or information may be misunderstood.  These gaps in communication can cause serious breakdown in continuity of care, inappropriate treatment and potential harm to the patient.  UK research estimates 10% adverse events in admissions (Department of Health, 2000) with similar rates in Australia and the US (Burnett, 2010) indicating problems with handovers widespread; indeed, this is an international and public concern (WHO, 2007).

Evidence-Based Practice

Evidence Based Practice (EBP) is defined by Dawes et al. (2005) as the following; ‘EBP requires that decisions about health and social care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources.’

Incorporating EBP within nursing is essential and is a professional, moral and ethical regulatory requirement from the Nursing and Midwifery Council (2008; 2010).   Failure to do so can result in professional misconduct and claims of negligence.  In 2005, the National Audit Office (DOH, 2005 – p.7) reported provisions for outstanding clinical negligence claims in excess of £2 billion as at end of 2003/04; 974,000 reported incidents/near misses in England in 2004/05 (excluding hospital acquired infections), with 2,181 resulting in death.  More recently, The Francis Report referred to inconsistent handovers as a contributory factor to serious failures in care at The Staffordshire NHS Trust (Francis, 2013).

The Nursing and Midwifery Council (2009) states the importance of handovers as vital communication points in which others rely on nursing records and imposes a duty to implement the latest relevant information whilst developing effective communication skills, yet there is very little evidence as to the actual reliability of clinical handovers, exacerbated by the fact that no universally agreed definitions or methods of studying handover exist (Burnett, 2010).

Moule and Goodman (2014) point to limitations in EBP in healthcare, particularly the lack of research evidence in mental health nursing and the cultural barriers, time and resources required to undertake such research; however, the benefits to patients are clear in light of the preceding statistics of risk to public health.

Locating and Appraising evidence

A systematic approach was developed to increase the chances of locating best evidence.  A question was formulated using the PICO framework (Aveyard and Sharp, 2013); ‘What is considered best practice (Outcome) within a nursing (Population) handover (Issue) psychiatric wards (Context)?  A Google search helped identify identified all possible synonyms of key words/terms from the question (Aveyard and Sharp, 2013).  Online databases searched included; the British Nursing Index (BNI) this is seen as a valuable resource for nurses, providing a UK and international perspective; the Cumulative Index to Nursing and Allied Health Literature Plus, known for detailed searching of nursing topics and is recommended as an additional source of literature after BNI (Royal College of Nursing, 2013); and Psychinfo, being a major literature resource for psychiatry and nursing (King’s College London, 2013).

Keywords were used with Boolean terms ‘AND’ and ‘OR’ to combine search terms, enabling literature selection for both, or either, terms respectively; ‘clinical’ OR ‘nurse’ AND ‘handover’ AND ‘unit’ OR ‘ward’.  To find variations in word forms, the truncation mark ‘*’ was added, e.g. nurs* to find ‘nurse’, ‘nurses’, ‘nursing’, ensuring these forms were not excluded (Barker, 2010, p. 46). The search was limited to items published between 2008 and 2014 to ensure the literature was up-to-date, to the English language to enable me to read the results and to peer-reviewed papers, as these give a degree of quality assurance (Moule and Goodman, 2014).

The search revealed a small number of results so were repeated, expanding the search worldwide and within the ‘full text’.  Although results doubled, numbers were low however, repeating this strategy on all databases revealed very similar references and I was confident my strategy was well focussed in accessing the relevant literature (Aveyard and Sharp, 2013).  Health websites were searched including; NHS Evidence, National Institute of Clinical Excellence, The Department of Health, The World Health Organisation and the Royal College of Nursing, using variations of key words previously used.  Reference lists were scanned to enable the identification of other sources that had not been referenced in the databases (Moule and Goodman, 2014).

The abstracts were scanned for relevance to the question, however, due to the small number of results relating to psychiatric nursing, handovers relating to other disciplines were not discarded.

As a wide variety of primary and secondary and non-research papers were located, a number of appraisal tools were selected to guide critical thinking appropriate to the source.  This enables the reviewer to ask questions specific to the literature type (Aveyard, 2014).  The critiquing tool, developed by Caldwell et al. (2011), was chosen; being adaptable to qualitative, quantitative and mixed methods studies.

Systematic/literature reviews were critiqued using the tool ‘Making sense of a review’ (CASP, 2013) and others were guided by the ‘six questions to trigger critical thinking’ by Mary Wooliams (Aveyard, 2009), because these help consider the strengths of any evidence.  However, when appraising the single review the Evaluation Tool for ‘Mixed Methods Study (Long et al. 2002) was chosen due to the level of detailed critiquing questions provided.

Findings – general overview

Nursing handover has received increasing attention over the last decade, particularly since 2007 (Scott et al. 2011), but according to the one systematic review located, no reliable evidence in the form of Randomised Control trials (RCT’s) exist which evaluate the effectiveness of nursing handovers to improve patient safety and care; although an RCT design is possible (Smeulers et al. (2014).  Unfortunately, few studies have been performed in psychiatric settings (Wong et al. 2008 and Young 2008 cited in Hunt et al. 2011), and both conclude more researchneeds to be carried out (Hunt et al. 2011; Smeulers et al. 2014).  Systematic reviews are usually considered the strongest forms of evidence as it reviews and summarises all studies around a topic; they also inform the evidence base for the National Institute of Clinical Evidence Guidelines (Aveyard, 2014).  However, the search did reveal a wide variety of reasonable quality primary/secondary research and other papers, mainly from the UK and Australia.  All were from reputable sources including Royal Colleges, NHS evidence and peer-reviewed journals.  Peer-reviewed journals can be an indicator of good quality (Aveyard, 2014).

One quantitative pilot study was found; Pothier et al. (2005) used a quasi-experimental design – considered the second best evidence for determining effectiveness (Aveyard and Sharpe, 2013) in the absence of the ‘gold standard’ RCT (Aveyard, 2014). Three nursing handover styles were studied finding loss of patient information in all styles – 1) verbal – receiver taking no notes (lost all data after three cycles; 2) verbal – receiver taking notes (retained 31% after the fifth cycle) 3) pre-prepared patient sheets utilised by both parties and complimented verbally (96.4% (lowest) retention at one cycle and 100% in 2 cycles, concluding the use of a pre-prepared sheet should be seriously considered.  Quantitative research collects data numerically so it can be measured and analysed (Aveyard and Sharpe, 2013) Sample sizes tend to be large to represent the population, therefore findings can be generalised to other contexts (Aveyard, 2014).  Sample size is a weakness in this study with four nurses/one location/five handover cycles.

The search revealed handover is complex, with multiple factors affecting efficiency/safety.  Five qualitative studies were sourced (Farhan et al. 2012; McMurray et al. 2010; Liu et al. 2012; McCloughen et al. 2008; Johnson et al. 2011). Most observed and/or taped handover and conducted interviews to ascertain current practice, identify deficits and recommend improvements.  McCoughen et al’s (2008) study revealed that some patients were not discussed at all, and upcoming interventions were rarely discussed, leading to questions for further research into how psychiatric nurses value handover.  Johnson et al. (2011) designed a generic ‘Nursing Handover Minimum Data Set’ (NH-MDS) to guide handover then observed 195 handovers, across 10 clinical settings (including mental health), to examine the presence of the NH-MDS, concluding data sets need to be adaptable to the patient context and setting as mental health (and midwifery) required further specific data sets.  Qualitative studies feature much lower down the hierarchy but the benefit here is the insight into handover function that would not be gained from an RCT; Although sample sizes tend to be small insights/interpretations can be generalisable to equivalent settings (Morse, 1999 cited in Aveyard, 2014).  One mixed methods study was located (Burnett et al. 2010) and will be appraised in the next section.  Other papers included: quality improvement initiatives (Currie and Watterson 2008; Gage 2013; Poh et al. 2013), literature reviews (Messam and Pettifer 2009; Matic et al. 2010; Scott et al. 2011) and guidelines (Bywaters et al. 2004; Toeima et al. 2010; World Health Organisation 2007) and were considered.  Common themes throughout particularly indicated the need for a standardised approach to structures and processes, due to inconsistencies.  Many advocate verbal handover complimented by use of a data sheet to ensure relevant and important information is not omitted, protected time free from interruptions, ongoing audit/evaluation of handover, managing change carefully, patient involvement, but perhaps most importantly, handover needs to be specific to the context and setting.  Many questions are being asked and further research is almost always concluded in the findings.

Findings – review of a single research report

The research chosen was undertaken by Burnett et al. 2010.  It is the first multi-centre UK study to examine the reliability of UK (NHS) healthcare systems and the impact of poor reliability on patient care in a range of organisations.  The researchers used a mixed methods design, combining qualitative and quantitative methods and was appraised using The Evaluative Tool for Mixed method Studies (Long, 2002).

Aims were clearly established: 1) to describe the nature, type, extent and variation of defects in healthcare system reliability that has potential to cause patient harm. 2) To provide research support for phase 1 and the design of phase two of the Safer Clinical Systems programme (SCS).  Acute medicine handovers were identified as one of five specific areas felt relevant for multi-centre study.  The quantitative part used a non-experimental approach, collecting data through handover observation to describe the level of standardisation, allowing exploration of the extent of variability between the organisations.  Qualitative semi-structured interviews were undertaken with each organisation asking about problems with clinical handovers.

Key findings:  A focus on immediate aspects of care rather than the end-to-end patient pathway; absence of a standard handover protocol; concurrent/competing demands preventing structured/formal handover; information not updated in real-time/information flow poor out-of-hours; reactive organisation culture, handover lower priority; no culture of questioning/challenging; no training in handover/other non-technical skills.

Three organisations (C, D and F) were chosen to represent a wide range of organisations aiming to be a sample representative of the UK. Selection was based on Patient Safety Measure Performance data to achieve diversity.  Diversity of participant/department recruitments and type of handover was a strength (C: neurology department; weekly consultant to consultant handover; D: Emergency department, shift handovers (x3 daily) between two senior doctors; F: Emergency medical assessment unit between incoming/outgoing medical teams/nurse), however sample sizes were small therefore questionable it is truly representative of other UK hospitals (Parahoo, 2014).

Quantitative data was collected through structured observations.  A core data sheet was utilised by the researcher to calculate percentage of patients for whom each item of the data was communicated.  The core items were agreed by the neurology department clinical lead with validation through agreement of the other two organisational leads.  Achieving consensus in this way is a strength; it is more likely the tool will represent the phenomenon (Parahoo, 2014). However, three weaknesses were apparent.  Some data was collected by the research team and others by existing staff trained by the researchers, introducing the possibility of observer bias (Bowling, 2009).  Moreover, handovers were not audio-taped so results were unverifiable for accurate representation.  Lastly, observing staff may have changed their behaviour.  This is known as the ‘Hawthorne’ effect and results could be distorted (Bowling, 2009), however remarkable similarities emerged across the organisations, strengthening the results of the study.

Qualitative data was collected by one researcher but from too small a sample to generalise (8), though there was general agreement among all interviewees, strengthening the findings. The collection method was questionable; not all interviews were audio-taped, others took detailed notes; some conducted face-to-face, others over the telephone.  These were transcribed however, one in four transcriptions were checked by a second researcher so accuracy of analysis may not be achieved. On the other hand, validity is enhanced in semi-structured interview, due to presence of the researcher as clarification can be sought from either party (Parahoo, 2014).

Awareness of ethical issues appeared a strength, in the main, with ethical committee approval.  Participants were provided an information sheet and invited to sign a consent form indicating their willingness to participate for the interviews, although it is not clear if consent for observation was obtained from team members, however, participation can indicate consent. They were free to leave the study, for no reason, at any time.  It was made clear that any serious breaches of practice would be reported.  Interviewee’s were offered the opportunity to review their transcripts and choose to exclude direct quotes.  Organisations, departments and people were anonymised in relation to the results.

Although this paper has a number of weaknesses, there are on balance a number of strengths.  Conclusions drawn seem reflective of findings making it a reasonable piece of research, in the absence of others.  In general mixed methods approaches are thought to increase overall quality, validity, reliability and trustworthiness.  This has enabled a more comprehensive view of handover, given the subjects complexity (Moule and Goodman, 2014).

This paper concurs with other papers throughout this report, therefore fitting entirely with the expected outcome; unstructured clinical handovers are unsafe and unreliable.

Can this evidence inform practice?

It is clear from the evidence there is a vital need and consensus (WHO, 2007) to change handover practices to improve patient care.  The risks are unacceptable and higher risks call for higher importance to be placed on basing our practice on evidence (Aveyard and Sharpe, 2013).  This report has highlighted a wide breadth of evidence that can inform practice in a guiding sense (WHO, 2007), although no rigorous systematic review or NICE guidelines exist specifically on which evidence can be strongly based (Moule and Hek, 2011).  That said, Burnett et al. (p.iv, 2010) are encouraging NHS leaders and practitioners to use their findings to consider how to improve reliability in their own organisations.

The use of change theories can assist with implementation of guidance; for example, the Plan, Do, Study, Act (PDSA) cycle approach used by the NHS can guide organisations through the planning and implementation of change (Moule and Hek, 2011), however the evidence has highlighted the need for handovers to be appraised within their unique contexts (McCloughen, 2008), so further work would need to be carried out to ascertain in-house needs.

A whole systems approach is suggested (Burnett et al. 2010; Bywaters et al. 2004) as multi-faceted interventions are more effective than single interventions (Moule and Hek, 2011) but changing established behaviour is difficult (NICE, 2007) with nursing handover practice firmly moulded by traditionally accepted customs (Sexton et al. 2004 cited in McCloughen, 2008).  A number of other implementation barriers are time pressures from caring for patients, lack of information technology and integration, lack of financial resources and staffing shortages (WHO, 2007).

Staff members need to be on board for change and to implement findings; this takes motivation but lacking motivation can be a significant barrier to change.  McMurray et al. (2010) found frontline nurses valued being part of an overall quality improvement strategy supported by senior staff.  Being part of the bigger picture influenced staff attitudes and understanding, resulting in a change in behaviour.  Nice Guidelines (p. 8, 2007) highlight motivation as a fundamental part of nearly everything we do, with external factors driving motivation thus changing behaviour.  Priorities, commitments, intentions and goals are all internal factors affecting motivation and ability to change.  Of course, staff many not have had the opportunity to engage with the evidence based literature around handovers resulting in a lack of awareness and knowledge of the need to change, therefore change cannot occur (NICE, 2007).  This is where staff in senior roles, promoting evidence based practice, can influence its use amongst staff through reaching agreed decisions on what is best practice (Aveyard and Sharpe, 2013).

Other factors include how much financial systems may constrain the resources into implementing change, especially a complex change such as handover (Nice, 2007).  For example, training staff costs money but skills are needed to know how best to carry out a change competently.  The Royal College of Obstetricians and Gynaecologists (2010) recommends the use of a handover tool, such as the SBAR, stating that the implementation of it may seem simple, however it takes a considerable amount of training across the organisation and Poh et al. (2013) states that translating evidence into practice can be made effective through ongoing evidence based audit.  We can start to appreciate that there are many cost implications, and at such a time when the NHS is heading towards major financial crisis (King’s Fund, 2014).

Implications for practice

Undertaking this research has made me appreciate the complexities of improving handover.  There appears to be a ‘good enough’ evidence base in which to make recommendations.  With this is mind, I plan use this knowledge to discuss the findings with the NHS organisation in which I am training as I believe this will make a marked difference in the care patients receive.  I am aware there is no formal handover policy within this organisation and as stated in the introduction, my personal reason for carrying out this research is due to the lack of standardisation witnessed amongst various sites.  I cannot identify any reasons against taking the knowledge from the research into practice.  After all, the research has pointed to the need for handover systems to be context specific, therefore it is not a clear cut procedure.  Through undertaking this report, I have also developed an appreciation of EBP and the need to question what I see, read and hear more critically rather than take information on face value.  I intend to engage with EBP on a regular basis, to increase my own knowledge and attempt to influence organisational practice.

Word Count:  3,222

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